Athletic Participation Physical Examination Form

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UPPER LOUDOUN YOUTH FOOTBALL LEAGUE
Purcellville, Virginia
Athletic Participation Physical Examination Form
PART I - PLAYER INFORMATION
Last Name: _________________________ First: __________________________
Phone:____________________
Address: __________________________________ City: _____________________ State: ______ Zip _____________
Date of Birth: ____________________________
September Grade: ______________
Sex: M___
F_____
PART II – MEDICAL HISTORY
Player Medical History
Yes
No
Explanation if Yes
1. Has a doctor ever denied or restricted your participation in
sports for any reason?
2. Do you have an ongoing medical condition? (Diabetes,
asthma, etc)?
3. Do you have allergies to medicines, pollens, foods or
stinging insects? Have you been diagnosed with Asthma or
Allergies?
4. Do you have a prescription for use of epinephrine, inhaler
or other allergy medications?
5. Have you ever passed out or nearly passed out during or
after exercise?
6. Do you cough, wheeze, or have difficulty breathing during
or after exercise?
7. Have you ever had a head injury or concussion? Where
you knocked unconscious? If yes, when?
8. What is the date of your last Tetanus immunization?
PART III – PHYSICAL EXAMINATION
To be filled out by Physician
Height: __________
Weight: __________ Sex: __________
Current Age: __________ DOB: __________
Vision: Corrected ( L) __________ (R) __________ (Both) __________
Uncorrected (L) __________ (R) __________ (Both) __________
BP: ________________
Pulse: (Rest) ______________ Exercise _______________
Recovery _______________
FEV or Peak Flow (Rest) _______________
Exercise _______________ Recovery _______________
N
ABNORMAL
N
ABNORMAL
Nutrition
Spine/Neck
Skin
Shoulders
Glands
Arm/Elbow/wrist/hand
Eyes
Knees/Hips
Ears
Ankle/Feet
Heart
Nose/Throat
Heart
Nervous System
Lungs
General Physical Comments: __________________________________________________________________________________
I have reviewed the data above, reviewed his/her medical history form and make the following recommendations for
his/her participation in ULYFL Football:
( )
CLEARED WITHOUT RESTRICTIONS
( ) NOT CLEARED FOR PARTICIPATION
Physician Signature: ________________________________
Date of Exam _________________________________
(MD, DO, LNP, PA)
Examiner’s Name Address and Degree (Print or Stamp)
Phone Number:________________________________
ULYFL USE: TEAM_______________________ OFFICIAL WEIGH IN WEIGHT: ___________
ALLERGY/ASTHMA:_______________________
This players Head Coach has been informed of any medical conditions of this player: ________ Player Agent Inititals: _________

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